A person with delirium or acute confusion commonly present in the following ways:

  • Being ‘muddled’ or ‘confused’.
  • ‘Not their usual self’.
  • ‘Drowsy’ or Hypoactive (‘they’re not responding to anything’).
  • Disorientated (in time, place or person).
  • Showing agitation or irritation.
  • Hallucinating.

It is critical to reassure and reorientate a person with delirium, and to obtain an accurate history about their usual state as soon as possible.

Delirium in the presence of known cognitive impairment like dementia is particularly difficult to diagnose without a good collateral history, but is vital to diagnose if present since it is potentially treatable and its management will improve immediate and longer term outcomes for the affected person.

Both conditions will often pose questions about a person’s capacity to make health and welfare decisions.  The Silver Book recommends that “all emergency sector professionals need to have a good knowledge of capacity and mental health legislation to deal appropriately with the person who is incapable of consenting to treatment.”

It also recommends that there is a local policy or procedure that requires all older people with cognitive impairment to be assessed for delirium using a standardised tool e.g., 4AT.

Typical underlying causes for delirium include acute infections, dehydration, medication side-effects, prolonged immobility and social isolation. The mnemonic “PINCH ME” can help to remember the more common causes:

  • Pain
  • Infection
  • Constipation
  • deHydration


  • Medication
  • Environmental changes


The NICE Pathway and associated documents can be accessed here.

NICE Information for the public is available here and below.


There is also a Quick Guide for Care Home Managers available here.

Let’s Respect: Delirium, Dementia and Depression provides a range of resources on their website